Rural Mental Health: Assertive Community Treatment – Overview, Challenges & Opportunities WICHE Mental Health Program Debra Kupfer, Consultant

Presentation Overview ACT Basics Small/Rural County Issues Adaptations to ACT Lessons Learned from Other States

Assertive Community Treatment Community-based program for adults with serious (& persistent ) mental illness Focus on independent living, employment and community tenure with assertive outreach “Team” staff approach Designated as an EBP

ACT Guidelines Small Caseload (Consumer/Provider ratio of 1:10) Team Approach Frequent Program Meetings Practicing Team Leader (direct services) Full Staffing with Continuity Psychiatrist (1 FTE per 100 consumers)

ACT Guidelines - continued Minimum of 2 Nurses per 100 Consumers Minimum of 2 SA Staff per 100 Consumers Minimum of 2 Voc. Staff per 100 Consumers Program Size: Sufficient to consistently provide the necessary staffing diversity and coverage

More About Staffing… Part-time Psychiatrist Team Leader (Masters level) Nurse(s) Social Workers, Psychologists (Masters level) Peer Staff Advocates Specialists: Vocational & Substance Abuse Paraprofessionals – community partners

ACT Treatment Responsibilities Full Responsibility for Individualized Treatment Services – case management, psychiatric services, counseling, housing support, SA treatment, and employment/ rehabilitation services In-vivo services Crisis Services ( 24/7) Hospital Admissions Hospital Discharge Planning – Continuity of Care Time Un-limited/Indefinite Services

Anticipated ACT Outcomes Increased independent living – decreased homelessness Improved employment status Decreased substance use Decreased hospitalization days Enhanced quality of life, increased socialization, reduced symptom severity/distress Targeted programs may decrease incarceration days Increased staff moral and retention

Challenge: Translating Research into Practice What’s different in small/rural counties?  Workforce & Staffing  Number of persons with S(P)MI – lack of ‘economy of scale’  Geography & Travel (time/distance)  Smaller Resource Pools

What Are Other Rural Folks Doing? Identifying and implementing the core components of an EBP such as ACT in a rural area can result in good clinical outcomes for rural consumers NAMI: “It is a pitfall to think that rural ACT means fewer services, fewer components, or less fidelity to the model”

Adapting ACT for Rural Development Workforce & Staffing  Availability of specific clinicians  Level of staffing necessary for small teams 24/7 coverage with small teams  Shared staffing with other programs & agencies Fully staffed team important, but difficult… refer consumers to other resources, such as employment & substance abuse specialists You can implement an ACT Team with 5-6 program staff, a part-time psychiatrist and a full-time administrative assistant (key to good communication) SC NAMI

Adapting ACT for Rural Development Number of persons with S(P)MI  Size of teams Rural team may have 25 consumers enrolled at one time Smaller teams are acceptable: consumers – most have at least 30 NAMI CO

Adapting ACT for Rural Development Geography & Travel Fewer numbers of contacts, however, the duration of contacts is longer Rural teams need to meet daily, face-to-face, including weekends Increased reliance on natural supports for travel Opportunities for use of more technology instead of relying on face-to-face meetings CO NAMI

Adapting ACT for Rural Development Smaller Resource Pools  Lack of an economy of scale  Benefits of collaborating and sharing resources more visible  Consumers better known to smaller communities ~ Opportunities to share resources ~ Using ER services, versus ACT staffing 24/7 ~ Consider discharging consumers from ACT SC

Consider a multi- community mental health center program

Adapting ACT for Rural Development Critical Components of ACT – South Carolina Perspective  Caseload size  Team approach  Communication  Community-based services  Assertive consumer engagement SC plans to get funding to research “ACT-like” Programs: Through indicators such as housing, employment, hospital and emergency department use. They will also be using the ACT Fidelity Scale. SC

Fidelity- Rural Considerations What is absolute and what is not? What modifications impact program outcomes? Monitoring fidelity versus/and outcomes When is the program no longer ACT? Only when outcomes are not achieved, is fidelity monitored HI

ACT is an Investment

Opportunities – Lessons Learned Leadership is key to the successful implementation of EBPs The role of supervisors is important Consumers & families are important partners Ongoing training & coaching support are necessary Need to incorporate EBPs into information systems & quality management ( The Need for an Evidence-Based Culture: Lessons Learned from Evidence-Based Practice Initiatives, Vijay Ganju, Ph.D., NRI-CMHQA, October 2006)

EBP Opportunities – Lessons Learned KS – Consumers involved in all stakeholder and skills training activities KS – Wish they had involved consumers at various levels from the start of the project NY – ACT training leader incorporated recovery concepts from the beginning ACT Toolkits – not much information about working with families OH - IDDT: Organizational culture changes – used to ask, “Can we contact your family?” and now ask, “ What family member should I contact?” OH – Cross-fertilize with sites IN – Use state standards for contracting with agencies that specify the use of fidelity measures CT – It has been extremely effective to have the CEO attend the trainings ( Implementing Evidence-Based Practices Project, National review of Effective Implementation Strategies and Challenges NRI-CMHQA, April 2003)

CA DMH Mission Statement The California Department of Mental Health, entrusted with leadership of the California mental health system, ensures through partnerships the availability and accessibility of effective, efficient, culturally competent services. This is accomplished by advocacy, education, innovation, outreach, understanding, oversight, monitoring, quality improvement, and the provision of direct services.